c c e e n n l l e e end-of-life nursing education consortium international curriculum symptom...

CCEENNLLEEEnd-of-Life Nursing Education Consortium

International CurriculumInternational Curriculum

Symptom Management

EE NN EE CCLL International CurriculumInternational Curriculum

Essential Elements of Symptom Management Essential Elements of

Symptom Management

• Ongoing assessment and evaluation

• Requires interdisciplinary teamwork

• Financial concerns (affordable options)

• Research is needed

Coyne et al., 2010

• Ongoing assessment and evaluation

• Requires interdisciplinary teamwork

• Financial concerns (affordable options)

• Research is needed

Coyne et al., 201022

Symptoms and SufferingSymptoms and Suffering

• Symptoms create suffering and distress

• Need for interdisciplinary care• Determine clinical intervention– Benefit (s)– Burden (s)– Risk (s)

• Symptoms create suffering and distress

• Need for interdisciplinary care• Determine clinical intervention– Benefit (s)– Burden (s)– Risk (s)

Common SymptomsCommon Symptoms• Respiratory– Dyspnea, cough

• GI– Anorexia/cachexia, constipation, diarrhea,

nausea/vomiting• Psychological– Depression, anxiety,

delirium/agitation/confusion• General/Systemic– Fatigue/weakness– Seizures– Fevers– Malaria

• Respiratory– Dyspnea, cough

• GI– Anorexia/cachexia, constipation, diarrhea,

nausea/vomiting• Psychological– Depression, anxiety,

delirium/agitation/confusion• General/Systemic– Fatigue/weakness– Seizures– Fevers– Malaria

DyspneaDyspnea

• Distressing shortness of breath• Associated diseases

Dudgeon, 2010

• Distressing shortness of breath• Associated diseases

Dudgeon, 2010

Causes of DyspneaCauses of Dyspnea

• Major pulmonary causes• Major cardiac causes• Major neuromuscular causes• Other causes

Assessment of DyspneaAssessment of Dyspnea

• Use subjective report• Clinical assessment– Physical exam– Diagnostic tests

Dudgeon, 2010

• Use subjective report• Clinical assessment– Physical exam– Diagnostic tests

Dudgeon, 2010

Treatment of DyspneaTreatment of Dyspnea

• Treating symptoms or underlying cause

• Pharmacologic treatments– Opioids– Bronchodilators– Diuretics– Other

Dudgeon, 2010; Jacobs, 2003

• Treating symptoms or underlying cause

• Pharmacologic treatments– Opioids– Bronchodilators– Diuretics– Other

Dudgeon, 2010; Jacobs, 2003

Treatment of DyspneaTreatment of Dyspnea

• Nonpharmacologic– Oxygen– Counseling– Pursed lip breathing– Energy conservation– Fans, elevation– Other

Dudgeon, 2010; Kravits & Berenson, 2010

• Nonpharmacologic– Oxygen– Counseling– Pursed lip breathing– Energy conservation– Fans, elevation– Other

Dudgeon, 2010; Kravits & Berenson, 2010

CoughCough

• Common symptom in advanced disease

• Causes pain, fatigue, insomnia

Dudgeon, 2010

• Common symptom in advanced disease

• Causes pain, fatigue, insomnia

Dudgeon, 2010

Causes of CoughCauses of Cough

• Assess underlying cause (e.g. infection, sinusitis, reflux)

• Assess type of cough• Assess associated symptoms• Diagnostic tests may be needed

Dudgeon, 2010

• Assess underlying cause (e.g. infection, sinusitis, reflux)

• Assess type of cough• Assess associated symptoms• Diagnostic tests may be needed

Dudgeon, 2010

Pharmacologic Interventions for Cough

• Suppressants/expectorants• Antibiotics• Steroids• Anticholinergics

Non-Pharmacologic Interventions for Cough

• Chest PT• Humidifier• Positioning

Anorexia and CachexiaAnorexia and Cachexia

• Anorexia - loss of appetite, usually with decreased intake

• Cachexia - lack of nutrition and wasting

Wholihan & Kemp, 2010

• Anorexia - loss of appetite, usually with decreased intake

• Cachexia - lack of nutrition and wasting

Causes of Anorexia and Cachexia

• Disease related• Psychological• Treatment related

Fearon et al., 2010; Wholihan & Kemp, 2010

Assessment of Anorexia and Cachexia

• Physical findings• Impact on function and quality of life• Calorie counts/daily weights• Lab tests• Skin breakdown

Treatment of Anorexia and Cachexia

• Dietary consultation• Medications• Parenteral/enteral nutrition• Odor control• Counseling

Earthman, 2002; MacDonald, 2003; Wholihan & Kemp, 2010

• Dietary consultation• Medications• Parenteral/enteral nutrition• Odor control• Counseling

Earthman, 2002; MacDonald, 2003; Wholihan & Kemp, 2010

ConstipationConstipation

• Infrequent passage of stool• Frequent symptom in palliative

care• Prevention is key

• Infrequent passage of stool• Frequent symptom in palliative

care• Prevention is key

Causes of ConstipationCauses of Constipation

• Disease related (e.g. obstruction, hypercalcemia, neurologic, inactivity)

• Treatment related (e.g. opioids, other meds)

• Disease related (e.g. obstruction, hypercalcemia, neurologic, inactivity)

• Treatment related (e.g. opioids, other meds)

Assessment of ConstipationAssessment of Constipation

• Bowel history• Abdominal assessment• Rectal assessment• Medication review

Economou, 2010

• Bowel history• Abdominal assessment• Rectal assessment• Medication review

Economou, 2010

Treatment of ConstipationTreatment of Constipation

• Medications• Dietary/fluids• Other approaches

Economou, 2010

• Medications• Dietary/fluids• Other approaches

Economou, 2010

DiarrheaDiarrhea

• Frequent passage of loose, nonformed stool

• Effects (e.g. fatigue, caregiver burden, skin breakdown)

• Frequent passage of loose, nonformed stool

• Effects (e.g. fatigue, caregiver burden, skin breakdown)

Causes of DiarrheaCauses of Diarrhea

• Disease related• Malabsorption• Concurrent diseases• Psychological• Treatment related

Assessment of DiarrheaAssessment of Diarrhea

• Bowel history• Medication review• Infectious processes

Treatment of DiarrheaTreatment of Diarrhea

• Treat underlying cause• Dietary modifications• Hydration• Pharmacologic agents

Nausea and VomitingNausea and Vomiting

• Common in advanced disease• Assessment of etiology is

important• Acute, anticipatory or delayed

Mannix, 2010

• Common in advanced disease• Assessment of etiology is

important• Acute, anticipatory or delayed

Mannix, 2010

Causes of Nausea and Vomiting

• Physiological (gastrointestinal, metabolic, central nervous system)

• Psychological• Disease related• Treatment related• Other

• Physiological (gastrointestinal, metabolic, central nervous system)

• Psychological• Disease related• Treatment related• Other

Assessment of Nausea and Vomiting

• Physical exam• History• Lab values

Pharmacologic Treatment of Nausea and Vomiting

• Anticholinergics• Antihistamines• Steroids• Prokinetic agents• Other

Non-Drug Treatment of Nausea and Vomiting

• Distraction/relaxation• Dietary• Small/slow feeding• Invasive therapies

FatigueFatigue

• Subjective, multidimensional experience of exhaustion

• Commonly associated with many diseases

• Impacts all dimensions of quality of life

Anderson et al., 2010; Ferrell et al., 1996

• Subjective, multidimensional experience of exhaustion

• Commonly associated with many diseases

• Impacts all dimensions of quality of life

Anderson et al., 2010; Ferrell et al., 1996

Causes of FatigueCauses of Fatigue

Assessment of FatigueAssessment of Fatigue

• Subjective• Objective• Laboratory data

Treatment of FatigueTreatment of Fatigue

• Pharmacologic• Nonpharmacologic (rest, energy

conservation, involve physical therapy/occupational therapy)

Anderson et al., 2010

• Pharmacologic• Nonpharmacologic (rest, energy

conservation, involve physical therapy/occupational therapy)

Anderson et al., 2010

DepressionDepression

• Ranges from sadness to suicidal• Often unrecognized and

undertreated• Distinguish normal vs. abnormal• Should not be dismissed

Pasacreta et al., 2010

• Ranges from sadness to suicidal• Often unrecognized and

undertreated• Distinguish normal vs. abnormal• Should not be dismissed

Causes of DepressionCauses of Depression

• Disease related• Psychological• Medication related• Treatment related

Assessment of DepressionAssessment of Depression

• Situational factors/symptoms• Previous psychiatric history• Other factors (e.g. lack of

support system, pain)

• Situational factors/symptoms• Previous psychiatric history• Other factors (e.g. lack of

support system, pain)

Example Questions for Depression AssessmentExample Questions for

Depression Assessment

• How have your spirits been lately?

• What do you see in your future?• What is the biggest problem you

are facing?

• How have your spirits been lately?

• What do you see in your future?• What is the biggest problem you

are facing?

Suicide AssessmentSuicide Assessment

• Do you think life isn’t worth living?

• Have you thought about how you would kill yourself?

• Do you think life isn’t worth living?

• Have you thought about how you would kill yourself?

Pharmacologic Interventions for Depression

• Antidepressants• Stimulants• Non-benzodiazepines• Steroids

Non-Pharmacologic Interventions for Depression

• Promote autonomy• Grief counseling• Draw on strengths• Use cognitive strategies

AnxietyAnxiety

• Subjective feeling of apprehension• Often without specific cause• Categories of mild, moderate,

severe

• Subjective feeling of apprehension• Often without specific cause• Categories of mild, moderate,

severe

Causes of AnxietyCauses of Anxiety

• Medications and substances• Uncertainty

Assessment of AnxietyAssessment of Anxiety

• Physical symptoms• Cognitive symptoms• Questions for assessment

APA, 2000

• Physical symptoms• Cognitive symptoms• Questions for assessment

APA, 2000

Pharmacologic Interventions for Anxiety

• Antidepressants• Benzodiazepines/anticonvulsants• Neuroleptics• Non-benzodiazepines

Non-pharmacologic Interventions for Anxiety

• Empathetic listening• Assurance and support• Concrete information/warning• Relaxation/imagery

Delirium/Agitation/Confusion

• Delirium - Acute change in cognition/awareness

• Agitation - accompanies delirium

• Confusion - disorientation, inappropriate behavior, hallucinations

Heidrich & English, 2010

• Delirium - Acute change in cognition/awareness

• Agitation - accompanies delirium

• Confusion - disorientation, inappropriate behavior, hallucinations

CausesCauses

• Infection• Medications• Hypoxemia• Bladder distention

Examples:Examples:

AssessmentAssessment

• Physical exam• History• Spiritual distress• Other symptoms

TreatmentTreatment

• Pharmacologic• Evaluate medications• Reorientation• Relaxation/distraction• Hydration

WoundsWounds

• Patients at risk• Prevention as key• Patients at risk• Prevention as key

Assessment of WoundsAssessment of Wounds

• Characteristics• Pain• Psychosocial• Caregivers

Treatment of WoundsTreatment of Wounds

• Wound cleaning• Dressings• Provide analgesia• Seek consultation

SeizuresSeizures

• Definition• Causes– Infections– Trauma– HIV– Tumors– Medications– Metabolic imbalances

Assessment for SeizuresAssessment for Seizures

• Manifestations– Aura– Mental status changes– Sensory changes

• Physical exam• Labs

• Manifestations– Aura– Mental status changes– Sensory changes

• Physical exam• Labs

Treatment for SeizuresTreatment for Seizures

• Limit trauma• Anticonvulsant treatments– Phenytoin– Phenobarbital– Lorazepam, diazepam

FeversFevers

• Definition• Causes– Infection– Tissue injury– Altered thermoregulation

Assessment/Treatment of FeversAssessment/Treatment of Fevers

• Clinical– Flushing– Malaise/fatigue

• Rigors/shaking• Treatment– Antibiotics– Antipyretics– Cooling measures

• Clinical– Flushing– Malaise/fatigue

• Rigors/shaking• Treatment– Antibiotics– Antipyretics– Cooling measures

MalariaMalaria

• High morbidity/mortality• Caused by a parasite• Use of prompt and effective

treatment WHO, 2010

• High morbidity/mortality• Caused by a parasite• Use of prompt and effective

treatment WHO, 2010

Symptoms/Treatment of MalariaSymptoms/Treatment of Malaria

• Fever• Chills• Headache• Nausea/vomiting

Key RolesKey Roles

• Patient advocacy• Assessment• Pharmacologic treatments• Non-pharmacologic treatments• Patient/family teaching

ConclusionConclusion

• Multiple symptoms common• Coordination of care with

physicians and others• Use drug and nondrug treatment• Patient/family teaching and support

• Multiple symptoms common• Coordination of care with

physicians and others• Use drug and nondrug treatment• Patient/family teaching and support

EE NN EE CCLL International CurriculumInternational CurriculumA Nurse's Touch 6363

Give the answers to the following questions please

1. List the respiratory symptoms that occur in palliative care patients?

2. What Non-pharmacologic Interventions for Anxiety do you know?

3. What are the causes of Delirium?

1. List the respiratory symptoms that occur in palliative care patients?

2. What Non-pharmacologic Interventions for Anxiety do you know?

3. What are the causes of Delirium?

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